| NPI | 1053093559 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: PA MA064755) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA064755) |
| Enumeration Date | 2023-08-03 |
| Last Update Date | 2023-08-07 |