| NPI | 1972183580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX V2014) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.149003) |
| Enumeration Date | 2021-04-09 |
| Last Update Date | 2024-06-27 |