| NPI | 1700854924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 27688) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 56185 020) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2012-10-17 |