| NPI | 1407264302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MO 2021015726) |
| Additional Taxonomies | 367H00000X Anesthesiologist Assistant (Licence: MO 2014030453) |
| Enumeration Date | 2014-07-24 |
| Last Update Date | 2021-05-21 |