| NPI | 1497043681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 70112) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: MN 58684) |
| Enumeration Date | 2011-07-21 |
| Last Update Date | 2018-11-30 |