| NPI | 1205405875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 79925) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 5151015341) |
| 207Q00000X Family Medicine (Licence: IA R-12405) | |
| Enumeration Date | 2021-06-18 |
| Last Update Date | 2025-05-22 |