| NPI | 1518900554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX R3857) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AR E-9484) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT1711) | |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2022-06-20 |