| NPI | 1508874868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: WY 7766A) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: WY 7766A) |
| Enumeration Date | 2006-08-03 |
| Last Update Date | 2012-08-01 |