| NPI | 1437568706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC LL36738) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2019-02732) |
| 207Q00000X Family Medicine (Licence: GA 83135) | |
| 261QU0200X Clinic/Center, Urgent Care | |
| Enumeration Date | 2014-08-12 |
| Last Update Date | 2023-12-31 |