| NPI | 1639630486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: MO 2022014198) |
| Additional Taxonomies | 2080S0010X Pediatrics, Sports Medicine (Licence: KS 94-10009) |
| Enumeration Date | 2019-03-26 |
| Last Update Date | 2026-09-23 |