| NPI | 1821386491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080A0000X Pediatrics, Adolescent Medicine (Licence: CA C163235) |
| Additional Taxonomies | 2080A0000X Pediatrics, Adolescent Medicine (Licence: WI 56059) |
| 208000000X Pediatrics (Licence: FL ME111081) | |
| Enumeration Date | 2011-07-18 |
| Last Update Date | 2020-11-09 |