| NPI | 1780973982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35.124187) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: OH 35.124187) |
| Enumeration Date | 2011-03-29 |
| Last Update Date | 2021-03-04 |