| NPI | 1184206773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KY 61646) |
| Additional Taxonomies | 208D00000X General Practice (Licence: KY 61646) |
| Enumeration Date | 2021-04-23 |
| Last Update Date | 2026-05-14 |