| NPI | 1780064568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.133468) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL38312) |
| Enumeration Date | 2015-06-05 |
| Last Update Date | 2020-11-20 |