| NPI | 1790045094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: SC 34586) |
| Additional Taxonomies | 2080S0010X Pediatrics, Sports Medicine (Licence: NC 39745) |
| Enumeration Date | 2012-05-21 |
| Last Update Date | 2012-05-21 |