| NPI | 1992233811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX S6906) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: TX S6906) |
| Enumeration Date | 2017-05-23 |
| Last Update Date | 2025-04-29 |