| NPI | 1750946091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MN 70277) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty (Licence: MN 70277) |
| Enumeration Date | 2019-05-02 |
| Last Update Date | 2022-11-10 |