| NPI | 1154767366 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 62865) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34012342) |
| Enumeration Date | 2013-05-14 |
| Last Update Date | 2022-07-21 |