| NPI | 1609877752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS12113) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34-00-4531) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2021-06-08 |