| NPI | 1508828948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 25137) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 50543-02) |
| 207Q00000X Family Medicine (Licence: IA 38114) | |
| Enumeration Date | 2006-04-03 |
| Last Update Date | 2013-02-04 |