| NPI | 1699410126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5151015442) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101029548) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OH 34.017938) | |
| Enumeration Date | 2022-04-29 |
| Last Update Date | 2026-08-05 |