| NPI | 1750945333 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NE 32848) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 32848) |
| Enumeration Date | 2019-04-29 |
| Last Update Date | 2025-11-06 |