NPI | 1700048915 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101017744) |
Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101017744) |
207QS0010X Family Medicine, Sports Medicine (Licence: OH 34.010276) | |
Enumeration Date | 2008-06-29 |
Last Update Date | 2022-09-09 |