| NPI | 1689789679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: TX L1731) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: FL ME45696) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2023-03-07 |