| NPI | 1013401462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty (Licence: KY 54933) |
| Additional Taxonomies | 261QS1000X Clinic/Center, Student Health |
| Enumeration Date | 2018-06-19 |
| Last Update Date | 2023-03-10 |