| NPI | 1528054301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine (Licence: MN 20245) |
| Additional Taxonomies | 207QA0401X Family Medicine, Addiction Medicine (Licence: KS 17663) |
| Enumeration Date | 2005-09-27 |
| Last Update Date | 2012-11-27 |