| NPI | 1114375532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 64747) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.068603) |
| Enumeration Date | 2016-05-26 |
| Last Update Date | 2020-09-29 |