| NPI | 1053731323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA 177416) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 59602) |
| Enumeration Date | 2014-04-24 |
| Last Update Date | 2022-07-05 |