| NPI | 1316507171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: OR DO209915) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: PA OT019361) |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2022-07-11 |