| 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 |