| NPI | 1891712394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 45968) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 39595) |
| 207Q00000X Family Medicine (Licence: MN 54388) | |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2020-09-16 |