| NPI | 1336520717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: TX R6413) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2015017145) |
| Enumeration Date | 2015-06-11 |
| Last Update Date | 2019-07-01 |