| NPI | 1093890535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9900826) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: NC 9900826) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2022-03-30 |