| NPI | 1720068810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: MN 51314) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: IA R-7339) |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2012-06-15 |