| NPI | 1285139717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2018-03-27 |
| Last Update Date | 2021-07-22 |