| NPI | 1568415750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080P0006X Pediatrics, Developmental - Behavioral Pediatrics (Licence: NE 23658) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 23658) |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2023-08-14 |