| NPI | 1891159802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX S4183) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA 308709) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TX S4183) | |
| Enumeration Date | 2016-04-06 |
| Last Update Date | 2021-04-12 |