| NPI | 1679720999 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 58795) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND 12075) |
| 207Q00000X Family Medicine (Licence: PA MT 193446) | |
| Enumeration Date | 2008-08-19 |
| Last Update Date | 2021-12-17 |