NPI | 1982228896 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 34.016394) |
Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5151014591) |
Enumeration Date | 2020-06-05 |
Last Update Date | 2023-06-19 |