| NPI | 1912317470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TN 56165) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: TN 56165) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: exempt) | |
| Enumeration Date | 2014-05-05 |
| Last Update Date | 2024-11-25 |