| NPI | 1902858855 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 63043) | 
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA md00035349) | 
| 207Q00000X Family Medicine (Licence: NH 13084) | |
| Enumeration Date | 2006-05-17 | 
| Last Update Date | 2022-10-10 |