| NPI | 1104958230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX N1905) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10025929) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX N1905) | |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2010-05-10 |