| NPI | 1194042887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MN 55632) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MN 55632) |
| 261Q00000X Clinic/Center (Licence: MN 55632) | |
| Enumeration Date | 2010-04-21 |
| Last Update Date | 2014-08-18 |