| NPI | 1205454592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty |
| Additional Taxonomies | 1744R1102X Specialist, Research Study |
| 174400000X Specialist | |
| Enumeration Date | 2020-07-13 |
| Last Update Date | 2023-08-29 |