| NPI | 1396130902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.146328) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD490123) |
| Enumeration Date | 2015-03-31 |
| Last Update Date | 2025-09-23 |