| NPI | 1356924476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QS1000X Clinic/Center, Student Health |
| Additional Taxonomies | 261QM2500X Clinic/Center, Medical Specialty |
| 207Q00000X Family Medicine (Licence: MS 31788) | |
| Enumeration Date | 2021-05-05 |
| Last Update Date | 2024-04-08 |