| NPI | 1629217880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 42917) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35-094977) |
| Enumeration Date | 2009-02-11 |
| Last Update Date | 2021-06-10 |