| NPI | 1043763188 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX V9125) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 299964) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-25 |
| Last Update Date | 2025-08-04 |