| NPI | 1821649930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME156771) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: TX 694410) |
| Enumeration Date | 2019-09-20 |
| Last Update Date | 2023-09-19 |