| NPI | 1912369695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MO 2016022483) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: KS 94-09120) |
| Enumeration Date | 2016-03-22 |
| Last Update Date | 2019-10-02 |