| NPI | 1922038348 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2080A0000X Pediatrics, Adolescent Medicine (Licence: OK 30099) | 
| Additional Taxonomies | 2080A0000X Pediatrics, Adolescent Medicine (Licence: OH 35088035) | 
| Enumeration Date | 2006-07-03 | 
| Last Update Date | 2013-10-24 |