| NPI | 1376742411 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: SC 29756) | 
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 29756) | 
| 208000000X Pediatrics (Licence: SC 29756) | |
| Enumeration Date | 2007-07-17 | 
| Last Update Date | 2025-06-18 |