| NPI | 1619263324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 63626) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA DO-04547) |
| 207Q00000X Family Medicine (Licence: WI 61870-21) | |
| Enumeration Date | 2011-06-21 |
| Last Update Date | 2025-11-19 |