| NPI | 1104990209 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: WA MD00045389) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: WI 55902-020) |
| 208000000X Pediatrics (Licence: WA MD00045389) | |
| 2080S0010X Pediatrics, Sports Medicine (Licence: WI 55902-020) | |
| 2080S0010X Pediatrics, Sports Medicine (Licence: CO DR.0052918) | |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2021-12-13 |