| NPI | 1639152150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 25299) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 41029) |
| Enumeration Date | 2005-11-29 |
| Last Update Date | 2011-02-23 |