| NPI | 1073976346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080S0010X Pediatrics Sports Medicine (Licence: TX S9702) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: OH 35.136410) |
| Enumeration Date | 2016-04-03 |
| Last Update Date | 2021-05-25 |