| NPI | 1679519540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 45304) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 3702) |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2012-02-21 |