| NPI | 1962775957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: CA A115656) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA A115656) |
| Enumeration Date | 2012-02-22 |
| Last Update Date | 2020-10-07 |