| NPI | 1245761485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 67555) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301500666) |
| Enumeration Date | 2017-03-21 |
| Last Update Date | 2020-07-07 |