| NPI | 1962453993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 40222) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 43122-020) |
| 207Q00000X Family Medicine (Licence: WY 8206A) | |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2011-11-10 |