| NPI | 1811489131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 344950) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 66657) |
| Enumeration Date | 2018-06-01 |
| Last Update Date | 2025-06-25 |