| NPI | 1790758191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 28769) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 29350) |
| 208100000X Physical Medicine & Rehabilitation (Licence: WI 28769) | |
| Enumeration Date | 2006-02-08 |
| Last Update Date | 2009-03-18 |