| NPI | 1154708022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QG0300X Family Medicine Geriatric Medicine (Licence: TX T4811) |
| Additional Taxonomies | 207QA0505X Family Medicine Adult Medicine (Licence: OK 35061) |
| 207Q00000X Family Medicine (Licence: MN 62790) | |
| Enumeration Date | 2015-04-29 |
| Last Update Date | 2024-03-17 |