| NPI | 1780048264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35.139042) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101283107) |
| Enumeration Date | 2016-04-11 |
| Last Update Date | 2025-09-24 |