| NPI | 1790034361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX F8560) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MD D24041) |
| 207Q00000X Family Medicine (Licence: LA 05010R) | |
| 207Q00000X Family Medicine (Licence: DC 17256) | |
| Enumeration Date | 2012-08-29 |
| Last Update Date | 2012-08-29 |