| NPI | 1770504011 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ND 7247) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 38266) |
| Enumeration Date | 2006-07-22 |
| Last Update Date | 2011-11-30 |