| NPI | 1588897896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MI 5101018472) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101018472) |
| 207QS0010X Family Medicine Sports Medicine (Licence: OH 34.010954) | |
| Enumeration Date | 2009-09-02 |
| Last Update Date | 2020-12-21 |