| NPI | 1134535511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 59492) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 69953) |
| Enumeration Date | 2014-07-07 |
| Last Update Date | 2021-04-26 |