| NPI | 1407449192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX U0583) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX U0583) |
| Enumeration Date | 2021-02-15 |
| Last Update Date | 2024-10-01 |