| NPI | 1568655652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX F0773) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA 40467) |
| Enumeration Date | 2007-08-22 |
| Last Update Date | 2023-03-20 |