| NPI | 1053803718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2021-02439) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10064548) |
| Enumeration Date | 2018-05-30 |
| Last Update Date | 2021-09-02 |