| NPI | 1740281286 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NY 202807) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: VT 042-0012168) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2022-07-13 |