| NPI | 1306864665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 30688) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 46259) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2012-12-19 |