| NPI | 1891255519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QS1000X Clinic/Center, Student Health |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: NC 2022-01811) |
| Enumeration Date | 2019-03-20 |
| Last Update Date | 2022-06-27 |