| NPI | 1326308057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301100818) |
| Additional Taxonomies | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) (Licence: MI 4301100818) |
| Enumeration Date | 2012-05-29 |
| Last Update Date | 2026-07-24 |