| NPI | 1871120568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2020-03-24 |
| Last Update Date | 2023-07-20 |