| NPI | 1619467867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: CT 68673) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL ME173745) |
| Enumeration Date | 2018-05-14 |
| Last Update Date | 2026-02-09 |