| NPI | 1073954475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 74487) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 65302) |
| Enumeration Date | 2013-07-13 |
| Last Update Date | 2024-04-23 |