| NPI | 1811971179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 37742) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 33633-20) |
| Enumeration Date | 2005-12-01 |
| Last Update Date | 2025-12-08 |