| NPI | 1336860774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: FL 1499) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: PR 022867) |
| Enumeration Date | 2022-09-05 |
| Last Update Date | 2023-08-02 |