| NPI | 1689650202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX N7979) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO DOR7006) |
| Enumeration Date | 2005-12-15 |
| Last Update Date | 2014-11-02 |