| NPI | 1699423459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: VA 0102208361) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-03-11 |
| Last Update Date | 2025-05-14 |