| NPI | 1922017623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MN 50252) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: OH 34-008344) |
| Enumeration Date | 2006-08-05 |
| Last Update Date | 2021-06-17 |