| NPI | 1346660883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 79903) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301112753) |
| Enumeration Date | 2014-04-23 |
| Last Update Date | 2025-10-15 |