| NPI | 1710064209 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OK 24591) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: 24591) |
| Enumeration Date | 2006-10-31 |
| Last Update Date | 2026-04-24 |