| NPI | 1376903682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NE 1742) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 1742) |
| 208D00000X General Practice (Licence: NE 1742) | |
| Enumeration Date | 2016-02-29 |
| Last Update Date | 2019-07-10 |