| NPI | 1093558579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX BP10090575) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 787020) |
| Enumeration Date | 2024-06-13 |
| Last Update Date | 2025-01-15 |