| NPI | 1801061981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) (Licence: PR 20339) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 17126) |
| Enumeration Date | 2008-04-29 |
| Last Update Date | 2023-06-23 |