| NPI | 1427158427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 52448) |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health (Licence: MN 52448) |
| 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: TX S5372) | |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2026-06-30 |