| NPI | 1972521524 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ND 4578) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 32391) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2022-04-29 |