| NPI | 1275080103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX S4923) |
| Additional Taxonomies | 261QE0002X Clinic/Center Emergency Care (Licence: PR 19431) |
| Enumeration Date | 2016-09-08 |
| Last Update Date | 2020-11-09 |