| NPI | 1457320558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: TX G4161) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX G4161) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2016-04-18 |