| NPI | 1154480507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: UT 6019928-1205) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: WI 50468) |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2021-10-21 |