| NPI | 1801208657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 89773) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34.012966) |
| Enumeration Date | 2014-05-28 |
| Last Update Date | 2021-10-13 |