| NPI | 1336127240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 50647 - 020) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 47641) |
| Enumeration Date | 2006-01-03 |
| Last Update Date | 2011-10-07 |