| NPI | 1568751790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 74060) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.124202) |
| Enumeration Date | 2011-03-28 |
| Last Update Date | 2024-12-06 |