| NPI | 1215748678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2025-01-15 |
| Last Update Date | 2025-01-15 |