| NPI | 1053467902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX N0853) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 19730) |
| Enumeration Date | 2007-01-25 |
| Last Update Date | 2012-09-12 |