| NPI | 1104096437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX N1756) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 26015) |
| Enumeration Date | 2008-03-03 |
| Last Update Date | 2017-01-10 |