| NPI | 1093039521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 81373561205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD70043786) |
| Enumeration Date | 2010-03-26 |
| Last Update Date | 2026-07-10 |