| NPI | 1639188147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX K1016) |
| Additional Taxonomies | 261QR1300X Clinic/Center, Rural Health (Licence: TX K1016) |
| Enumeration Date | 2006-08-05 |
| Last Update Date | 2011-06-01 |