| NPI | 1982059259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080P0006X Pediatrics, Developmental - Behavioral Pediatrics (Licence: RI CLP05904) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101262866) |
| 208000000X Pediatrics (Licence: VA 0101262866) | |
| Enumeration Date | 2016-04-25 |
| Last Update Date | 2026-07-22 |