| NPI | 1225449861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP60755393) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX 584075) |
| 207Q00000X Family Medicine (Licence: TX R0886) | |
| Enumeration Date | 2014-05-16 |
| Last Update Date | 2018-03-07 |