| NPI | 1235635376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD.MD.61358820) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX T3614) |
| Enumeration Date | 2018-04-05 |
| Last Update Date | 2026-05-27 |