| NPI | 1649385840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: OR MD13769) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: WA MD00037126) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2007-07-08 |