| NPI | 1295796480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2015-0091) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX G7610) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TX G7610) | |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2016-02-05 |