| NPI | 1811011869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX M5127) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: TX 138537) |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2023-03-07 |