| NPI | 1154785616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 11273463-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 62587) |
| 2084A0401X Psychiatry & Neurology, Addiction Medicine (Licence: UT 11273463-1204) | |
| Enumeration Date | 2016-04-11 |
| Last Update Date | 2019-06-18 |