| NPI | 1649730193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35.148876) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.148876) |
| Enumeration Date | 2019-03-21 |
| Last Update Date | 2023-08-30 |