| NPI | 1063499093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60367744) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 30191) |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2026-07-09 |