| NPI | 1255626503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 9041861-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MR-1192) |
| Enumeration Date | 2011-06-15 |
| Last Update Date | 2026-04-03 |