| NPI | 1407840259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX P3667) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA04004) |
| Enumeration Date | 2005-09-08 |
| Last Update Date | 2020-10-09 |