| NPI | 1083173405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL TRN42496) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator (Licence: FL CBHCM102175-P) |
| Enumeration Date | 2019-03-15 |
| Last Update Date | 2025-06-04 |