| NPI | 1770659765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX Q9880) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: IN 01062764A) |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2019-10-30 |