| NPI | 1952893844 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 14196576-1204) | 
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 72281-21) | 
| Enumeration Date | 2018-06-05 | 
| Last Update Date | 2025-03-18 |