| NPI | 1104355049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: CA A157790) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA A157790) |
| 208D00000X General Practice (Licence: CA A157790) | |
| Enumeration Date | 2017-06-05 |
| Last Update Date | 2023-08-03 |