| NPI | 1760821763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 13574897-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0102204000) |
| 207Q00000X Family Medicine (Licence: AZ 011437) | |
| Enumeration Date | 2013-06-24 |
| Last Update Date | 2024-12-31 |