| NPI | 1790929396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: CA C40168) |
| Additional Taxonomies | 2080S0010X Pediatrics, Sports Medicine (Licence: LA MD.012864) |
| Enumeration Date | 2009-04-27 |
| Last Update Date | 2009-12-02 |