| NPI | 1780114512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: PA MD471170) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: PA MT212772) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2021-09-22 |