| NPI | 1528409711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX R9316) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX R9316) |
| 208600000X Surgery (Licence: PA MT204712) | |
| Enumeration Date | 2013-07-16 |
| Last Update Date | 2020-08-20 |