| NPI | 1932269842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX BP10057839) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9991) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2016-05-18 |