| NPI | 1467089565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX T2837) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-03-26 |
| Last Update Date | 2024-05-09 |