| NPI | 1700220001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX Q8968) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2016023350) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-04-17 |
| Last Update Date | 2017-11-09 |