| NPI | 1700310166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 82875) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 69743) |
| Enumeration Date | 2017-04-12 |
| Last Update Date | 2026-08-12 |