| NPI | 1982497889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA67312) |
| Enumeration Date | 2025-05-23 |
| Last Update Date | 2026-07-09 |