| NPI | 1497036933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102203221) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102203221) |
| 171000000X Military Health Care Provider (Licence: TX U5488) | |
| 207Q00000X Family Medicine (Licence: TX U5488) | |
| Enumeration Date | 2011-08-29 |
| Last Update Date | 2023-08-02 |