| NPI | 1679891576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX R3709) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX 549804) |
| 208600000X Surgery (Licence: SC 33671) | |
| 208600000X Surgery (Licence: TX BP1 0036959) | |
| Enumeration Date | 2010-05-17 |
| Last Update Date | 2019-06-11 |