| NPI | 1366601692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: HI 15665) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: HI MD-15665) |
| Enumeration Date | 2008-06-02 |
| Last Update Date | 2023-12-07 |