| NPI | 1073995718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 74525) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME143661) |
| 207Q00000X Family Medicine (Licence: MI 4301108152) | |
| Enumeration Date | 2015-06-18 |
| Last Update Date | 2026-06-19 |