| NPI | 1679968788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 042.0016745) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.133104) |
| Enumeration Date | 2015-04-06 |
| Last Update Date | 2023-04-05 |