| NPI | 1568409522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9601205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX Q1828) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 9601205) | |
| Enumeration Date | 2006-05-31 |
| Last Update Date | 2022-12-09 |