| NPI | 1962535617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX R9894) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL 0S6853) |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2023-08-09 |