| NPI | 1083308720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: VA 0101283714) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-06-06 |
| Last Update Date | 2026-07-21 |