| NPI | 1073564126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 32307-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 37146) |
| Enumeration Date | 2006-05-13 |
| Last Update Date | 2017-07-14 |