| NPI | 1063892933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NY 300402) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 608878794) |
| Enumeration Date | 2015-06-04 |
| Last Update Date | 2019-12-03 |