| NPI | 1891995338 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 33351) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 33351) |
| Enumeration Date | 2007-07-23 |
| Last Update Date | 2020-05-27 |