| NPI | 1114612017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX W6316) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: TN 75541) |
| Enumeration Date | 2023-04-06 |
| Last Update Date | 2026-06-29 |