NPI | 1053792200 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD.MD.61537270) |
Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX S9307) |
Enumeration Date | 2015-06-13 |
Last Update Date | 2024-05-10 |