| NPI | 1164698619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MN 52435) |
| Additional Taxonomies | 207QA0401X Family Medicine, Addiction Medicine (Licence: MN 52435) |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2008-05-05 |
| Last Update Date | 2024-02-15 |