| NPI | 1265846042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301106112) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35146176) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2025-08-11 |