| NPI | 1912194804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA C160453) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 53917) |
| 207Q00000X Family Medicine (Licence: MN 50156) | |
| Enumeration Date | 2007-09-25 |
| Last Update Date | 2020-02-20 |