| NPI | 1982681029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: WA MD00027556) |
| Additional Taxonomies | 174400000X Specialist (Licence: WA MD00027556) |
| Enumeration Date | 2005-12-29 |
| Last Update Date | 2020-01-13 |