| NPI | 1366594293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9400542) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care |
| 2084A0401X Psychiatry & Neurology, Addiction Medicine (Licence: NC 9400542) | |
| Enumeration Date | 2007-01-18 |
| Last Update Date | 2023-07-07 |