| NPI | 1003437310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: PA MT220997) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 325482) |
| Enumeration Date | 2020-04-28 |
| Last Update Date | 2025-04-08 |