| NPI | 1619967155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 37002) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 31540) |
| Enumeration Date | 2005-10-26 |
| Last Update Date | 2021-12-27 |