| NPI | 1376692079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX 942244) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX D1001) |
| 207Q00000X Family Medicine (Licence: TX 74-1752692) | |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2022-08-24 |