| NPI | 1053312256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 40304-020) |
| Additional Taxonomies | 208600000X Surgery (Licence: WI 40304-020) |
| 207Q00000X Family Medicine (Licence: MN 43240) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2011-11-18 |