| NPI | 1790367373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 13819074-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX U2201) |
| 207Q00000X Family Medicine (Licence: UT 13819074-1204) | |
| Enumeration Date | 2021-04-23 |
| Last Update Date | 2026-09-16 |