| NPI | 1700815131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102202366) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34.006884) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2021-01-05 |