| NPI | 1699974378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 57730) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 24211) |
| 207Q00000X Family Medicine (Licence: IA R-8050) | |
| Enumeration Date | 2007-07-13 |
| Last Update Date | 2018-10-01 |