| NPI | 1962484733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX G8488) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: TX G8488) |
| Enumeration Date | 2005-11-17 |
| Last Update Date | 2010-09-14 |