| NPI | 1083699300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: AK 7284) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: FL ME85849) |
| 208000000X Pediatrics (Licence: NC 2010-01016) | |
| Enumeration Date | 2005-12-09 |
| Last Update Date | 2023-03-07 |