| NPI | 1104820851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 16251) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 30384) |
| 207Q00000X Family Medicine (Licence: WI 24773) | |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2009-07-30 |