| NPI | 1649301714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NC 200501870) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: NC 200501870) |
| Enumeration Date | 2007-03-08 |
| Last Update Date | 2021-09-01 |