| NPI | 1639311681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD177267) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35096724) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD60665893) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301093075) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OR MD177267) | |
| 207Q00000X Family Medicine (Licence: WA MD60665893) | |
| Enumeration Date | 2009-04-06 |
| Last Update Date | 2025-09-08 |