| NPI | 1154548410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080A0000X Pediatrics, Adolescent Medicine (Licence: NV 16060) |
| Additional Taxonomies | 2080A0000X Pediatrics, Adolescent Medicine (Licence: NY 162398) |
| 208D00000X General Practice (Licence: NY 162398) | |
| Enumeration Date | 2007-04-19 |
| Last Update Date | 2022-07-21 |