| NPI | 1538454780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CO 53891) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10041636) |
| Enumeration Date | 2011-06-16 |
| Last Update Date | 2014-10-02 |