| NPI | 1134577067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 34.013915) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 58.007899) |
| Enumeration Date | 2016-06-01 |
| Last Update Date | 2020-12-31 |