| 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 |