| NPI | 1164803375 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: TX S6061) | 
| Additional Taxonomies | 208000000X Pediatrics (Licence: AZ 007585) | 
| 208000000X Pediatrics (Licence: TX S6061) | |
| Enumeration Date | 2015-06-12 | 
| Last Update Date | 2025-08-19 |