| NPI | 1043607112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 79047) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX 591536) |
| Enumeration Date | 2015-04-16 |
| Last Update Date | 2021-05-14 |