| NPI | 1003811415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 75212-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX J8333) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2024-12-10 |