| NPI | 1013394345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: GA 85352) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 804073536) | |
| Enumeration Date | 2015-05-06 |
| Last Update Date | 2020-05-20 |