| NPI | 1114328267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080P0006X Pediatrics, Developmental - Behavioral Pediatrics (Licence: OH 35.140137) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2014-09-09 |
| Last Update Date | 2020-07-23 |