| NPI | 1114207891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME125174) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL TRN16384) |
| Enumeration Date | 2011-08-25 |
| Last Update Date | 2015-08-06 |