| NPI | 1699706317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 0420009937) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 44142) |
| 207Q00000X Family Medicine (Licence: MN 44498) | |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2007-07-08 |