| NPI | 1760777130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2026-01722) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX Q6703) |
| Enumeration Date | 2011-06-14 |
| Last Update Date | 2026-04-14 |