| NPI | 1386646669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: WY 8034A) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: WY 8034A) |
| 207Q00000X Family Medicine (Licence: WY 8034A) | |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2023-07-13 |