| NPI | 1053815761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: OH 35.151163) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208000000X Pediatrics (Licence: MI 4301507076) | |
| 208000000X Pediatrics (Licence: NY 308880) | |
| Enumeration Date | 2018-03-19 |
| Last Update Date | 2024-07-16 |