| NPI | 1689109761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KY 57386) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: KY TP149) |
| Enumeration Date | 2017-04-26 |
| Last Update Date | 2023-04-11 |