| NPI | 1619311586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 59639) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 65487) |
| Enumeration Date | 2013-04-23 |
| Last Update Date | 2021-03-08 |