| NPI | 1104889674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080A0000X Pediatrics Adolescent Medicine (Licence: MI NH033036) |
| Additional Taxonomies | 174400000X Specialist (Licence: MI NH033036) |
| Enumeration Date | 2006-04-07 |
| Last Update Date | 2021-03-03 |