| NPI | 1902330772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SD 12107) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 64643) |
| Enumeration Date | 2017-04-18 |
| Last Update Date | 2020-08-05 |