| NPI | 1497485320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301510702) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.149610) |
| Enumeration Date | 2022-06-14 |
| Last Update Date | 2026-04-14 |