| NPI | 1457598443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 202K00000X (Licence: TX N9698) |
| Additional Taxonomies | 202K00000X (Licence: CO 50256) |
| 207Q00000X Family Medicine (Licence: TX N9698) | |
| 207Q00000X Family Medicine (Licence: CO 50256) | |
| Enumeration Date | 2009-01-13 |
| Last Update Date | 2022-11-11 |