| NPI | 1972169258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: LA 332413) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: MI 4301513688) |
| Enumeration Date | 2019-05-13 |
| Last Update Date | 2026-08-03 |