| NPI | 1609396118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX T7236) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX 47071) |
| Enumeration Date | 2017-06-26 |
| Last Update Date | 2026-04-13 |