| NPI | 1104230408 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 67746) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 59583) |
| Enumeration Date | 2014-06-13 |
| Last Update Date | 2022-07-21 |