| NPI | 1174508618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SD 7464) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND 20374) |
| 207Q00000X Family Medicine (Licence: TX H2541) | |
| Enumeration Date | 2005-12-07 |
| Last Update Date | 2026-07-06 |