| NPI | 1699756957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OK 2098) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX J7525) |
| Enumeration Date | 2005-11-14 |
| Last Update Date | 2010-01-23 |