| NPI | 1205567641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 80473) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND 18525) |
| Enumeration Date | 2022-06-17 |
| Last Update Date | 2025-08-29 |