| NPI | 1962434357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 37245) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 33434-20) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2025-09-10 |