| NPI | 1902836976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: CT 042829) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 233345-1) |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2011-05-11 |