| NPI | 1891797510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 34.002926) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101011998) |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2014-10-29 |