| NPI | 1003112657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 108161) |
| Additional Taxonomies | 208600000X Surgery (Licence: OH 57.018214) |
| Enumeration Date | 2011-01-31 |
| Last Update Date | 2022-05-13 |