| NPI | 1407386881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MN 68621) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 53620) |
| 207Q00000X Family Medicine (Licence: MN 68621) | |
| Enumeration Date | 2017-06-18 |
| Last Update Date | 2024-01-05 |