| NPI | 1215289616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX D1717) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL 17845) |
| 207Q00000X Family Medicine (Licence: MS 09690) | |
| Enumeration Date | 2012-10-09 |
| Last Update Date | 2012-10-09 |