| NPI | 1184988024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: WI 57320) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 57320) |
| 261QA0600X Clinic/Center, Adult Day Care (Licence: WI 57320) | |
| Enumeration Date | 2012-06-26 |
| Last Update Date | 2021-12-01 |