| NPI | 1861735292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: OH 35.140363) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 282913) |
| Enumeration Date | 2013-04-04 |
| Last Update Date | 2022-03-01 |