| NPI | 1154414258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME83660) |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization (Licence: FL ME83660) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2024-04-25 |