| NPI | 1306339502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 69461) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2018019014) |
| Enumeration Date | 2018-06-12 |
| Last Update Date | 2021-09-02 |