| NPI | 1619388006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 59525) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 59525) |
| Enumeration Date | 2014-05-19 |
| Last Update Date | 2021-06-17 |