| NPI | 1265576516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT MED-PHYS-LIC-120488) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX J5768) |
| 207Q00000X Family Medicine (Licence: MO 2024029857) | |
| Enumeration Date | 2007-02-19 |
| Last Update Date | 2026-01-12 |