| NPI | 1053381558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 993746751205) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty (Licence: UT 3746751205) |
| 261QM1300X Clinic/Center, Multi-Specialty (Licence: UT 3746758905) | |
| Enumeration Date | 2006-01-25 |
| Last Update Date | 2015-09-24 |