| NPI | 1902241235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: WA OP61442055) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: ID O-0924) |
| Enumeration Date | 2013-04-30 |
| Last Update Date | 2023-08-10 |