| NPI | 1801090246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080H0002X (Licence: FL ME110544) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: OH 093600) |
| 208000000X Pediatrics (Licence: MO 2005018765) | |
| Enumeration Date | 2007-06-11 |
| Last Update Date | 2019-07-01 |