| NPI | 1972130292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: HI MD-22352) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: HI MD-22352-0) |
| 208D00000X General Practice (Licence: HI MD-22352-0) | |
| Enumeration Date | 2020-03-25 |
| Last Update Date | 2025-08-12 |