| NPI | 1114362175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QU0200X Clinic/Center, Urgent Care |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2013-05-05 |
| Last Update Date | 2019-03-28 |