| NPI | 1063467538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 3416A) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: CA A31472) |
| 261QU0200X Clinic/Center, Urgent Care (Licence: WY 3416A) | |
| Enumeration Date | 2006-05-23 |
| Last Update Date | 2021-01-23 |