| NPI | 1952508145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX Q1783) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2020-11-19 |