| NPI | 1295964682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: AL 30426) |
| Additional Taxonomies | 261QR1300X Clinic/Center, Rural Health (Licence: AL 30426) |
| Enumeration Date | 2009-07-07 |
| Last Update Date | 2022-08-11 |