| NPI | 1316907454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 38043) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: WI 38043) |
| 207Q00000X Family Medicine (Licence: MN 80837) | |
| 261QU0200X Clinic/Center, Urgent Care (Licence: MN 80837) | |
| Enumeration Date | 2006-03-24 |
| Last Update Date | 2025-11-10 |