| NPI | 1720668692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 81583) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 75255) |
| Enumeration Date | 2021-04-13 |
| Last Update Date | 2024-09-20 |