| NPI | 1134623721 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 79304) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 75849-02) |
| 207Q00000X Family Medicine (Licence: OH 35.140164) | |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2025-09-16 |