| NPI | 1174040364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MN 68846) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: WI 103484-875) |
| Enumeration Date | 2017-08-28 |
| Last Update Date | 2026-02-04 |