| NPI | 1013458363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL OS16534) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2017-03-19 |
| Last Update Date | 2022-07-27 |