| NPI | 1659720704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KS 04-42344) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: VT 042-0014800) |
| Enumeration Date | 2016-06-09 |
| Last Update Date | 2020-07-13 |