| NPI | 1780203208 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: TX U3291) | 
| Additional Taxonomies | 208000000X Pediatrics (Licence: TX U3291) | 
| Enumeration Date | 2020-04-14 | 
| Last Update Date | 2025-06-13 |