| NPI | 1356592968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KY 54953) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL ME110633) |
| Enumeration Date | 2008-10-02 |
| Last Update Date | 2023-08-02 |