| NPI | 1760677520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0401X Family Medicine Addiction Medicine (Licence: UT 322409-1204) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization (Licence: UT 963224091204) |
| Enumeration Date | 2007-09-13 |
| Last Update Date | 2021-11-03 |