| NPI | 1962069203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX T3974) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA 61105083) |
| Enumeration Date | 2019-05-22 |
| Last Update Date | 2025-07-16 |