| NPI | 1740210624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL 58309) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: FL 58309) |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2016-07-15 |