| NPI | 1104564590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: MN 81748) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MN 32700) |
| 208D00000X General Practice (Licence: MI 4301516323) | |
| Enumeration Date | 2022-05-25 |
| Last Update Date | 2026-03-21 |