| NPI | 1437967205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty (Licence: AZ R81380) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: AZ R81380) |
| Enumeration Date | 2024-12-24 |
| Last Update Date | 2025-01-14 |