| NPI | 1053311068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AR E3830) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX M3478) |
| Enumeration Date | 2005-08-01 |
| Last Update Date | 2021-04-09 |