| NPI | 1730465980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX R4387) |
| Additional Taxonomies | 208D00000X General Practice (Licence: AL 31255) |
| Enumeration Date | 2011-11-01 |
| Last Update Date | 2022-06-30 |