| NPI | 1205255866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX S5497) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: GA 77926) |
| Enumeration Date | 2014-04-10 |
| Last Update Date | 2020-07-06 |