| NPI | 1255863684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 69437) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 304195) |
| Enumeration Date | 2017-04-03 |
| Last Update Date | 2021-07-29 |