| NPI | 1760483242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KY 13868) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL ME123112) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2020-10-26 |