| NPI | 1487030417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX R8190) |
| Additional Taxonomies | 208D00000X General Practice (Licence: TX BP10053714) |
| Enumeration Date | 2015-07-31 |
| Last Update Date | 2018-08-29 |