| NPI | 1639564800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: OH 35139480) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: KY 51499) |
| Enumeration Date | 2015-04-03 |
| Last Update Date | 2020-07-08 |