| NPI | 1811159650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME 112012) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10030674) |
| Enumeration Date | 2008-07-01 |
| Last Update Date | 2025-12-30 |