| NPI | 1154916740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME158456) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-03-04 |
| Last Update Date | 2024-07-15 |