| NPI | 1982229035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 12537742-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-06-15 |
| Last Update Date | 2025-07-31 |