| NPI | 1053815761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MI 4301507076) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 308880) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-19 |
| Last Update Date | 2023-09-05 |