| NPI | 1700129228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX S8657) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: NE 28090) | |
| 171000000X Military Health Care Provider (Licence: NE 28090) | |
| Enumeration Date | 2013-04-03 |
| Last Update Date | 2022-12-18 |