| NPI | 1558308304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101263477) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 47794) |
| Enumeration Date | 2006-06-01 |
| Last Update Date | 2021-07-21 |