| NPI | 1902033376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: TX U2674) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 780) |
| Enumeration Date | 2009-06-12 |
| Last Update Date | 2024-07-18 |