| NPI | 1043570617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL 34205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX 193400000X) |
| Enumeration Date | 2012-05-16 |
| Last Update Date | 2019-10-11 |