| NPI | 1235395625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME143047) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: PR 18126) |
| Enumeration Date | 2008-08-05 |
| Last Update Date | 2022-06-17 |