| NPI | 1881697852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 15040R) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX M5211) |
| Enumeration Date | 2005-05-24 |
| Last Update Date | 2021-02-26 |