| NPI | 1043875453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NC 2022-01458) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 250357) |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2022-08-26 |