| NPI | 1619973146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME 101452) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: OH 35-04-8034-S) |
| Enumeration Date | 2005-06-21 |
| Last Update Date | 2017-03-22 |