| NPI | 1740945484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2025032417) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10080341) |
| Enumeration Date | 2021-11-08 |
| Last Update Date | 2025-08-25 |