| NPI | 1891100251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX T4824) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 292761) |
| Enumeration Date | 2014-06-24 |
| Last Update Date | 2022-11-08 |