| NPI | 1639311681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35096724) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301093075) |
| Enumeration Date | 2009-04-06 |
| Last Update Date | 2022-02-14 |