| NPI | 1942569454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) (Licence: FL OS13407) |
| Additional Taxonomies | 2080P0203X Pediatrics, Pediatric Critical Care Medicine (Licence: FL OS13407) |
| 207Q00000X Family Medicine (Licence: FL OS13407) | |
| 2080P0203X Pediatrics, Pediatric Critical Care Medicine (Licence: LA 334596) | |
| 2080P0203X Pediatrics, Pediatric Critical Care Medicine (Licence: MI EMC0003171) | |
| Enumeration Date | 2012-05-04 |
| Last Update Date | 2026-09-10 |