| NPI | 1821520792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35.139374) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD70096404) |
| Enumeration Date | 2017-03-30 |
| Last Update Date | 2026-08-21 |