| NPI | 1962814863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MO 2023013098) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: KS 04-47505) |
| Enumeration Date | 2014-05-27 |
| Last Update Date | 2025-02-13 |