| NPI | 1417523606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OK 43832) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT223111) |
| Enumeration Date | 2021-05-28 |
| Last Update Date | 2025-04-17 |