| NPI | 1457302135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 39414-020) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 40575) |
| 207Q00000X Family Medicine (Licence: SD 4366) | |
| 207Q00000X Family Medicine (Licence: IA 30546) | |
| 207Q00000X Family Medicine (Licence: ND 9796) | |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2007-07-08 |