| NPI | 1528468527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX Q1185) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: TX Q1185) |
| Enumeration Date | 2014-08-26 |
| Last Update Date | 2022-10-03 |