| NPI | 1457346124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080P0006X Pediatrics, Developmental - Behavioral Pediatrics (Licence: VT 042-0006288) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: VT 0420006288) |
| 208000000X Pediatrics (Licence: VT 042-0006288) | |
| Enumeration Date | 2005-09-19 |
| Last Update Date | 2011-06-02 |