| NPI | 1013360353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME161128) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NM MD2019-0297) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-21 |
| Last Update Date | 2025-06-12 |