| NPI | 1902161177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: LA 207988) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: LA GETP.200986) |
| 208000000X Pediatrics (Licence: TN 54631) | |
| 2080S0010X Pediatrics, Sports Medicine (Licence: MO 2020020214) | |
| Enumeration Date | 2012-07-12 |
| Last Update Date | 2021-08-05 |