| NPI | 1417377755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 70608) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 64464) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: MN 70608) | |
| Enumeration Date | 2014-04-25 |
| Last Update Date | 2024-05-09 |