| NPI | 1760862494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR DO187078) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 60835) |
| Enumeration Date | 2015-06-08 |
| Last Update Date | 2021-03-22 |