| NPI | 1679033930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 325906) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.143299) |
| Enumeration Date | 2019-03-22 |
| Last Update Date | 2023-09-27 |