| NPI | 1073993911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: LA 320811) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: SC LL37644) |
| Enumeration Date | 2015-06-05 |
| Last Update Date | 2019-08-30 |