| NPI | 1114362621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: WI 5105-320) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: IL 036-172765) |
| 208000000X Pediatrics (Licence: MD D81432) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MD P-625-603-734-927) | |
| Enumeration Date | 2013-05-10 |
| Last Update Date | 2025-03-12 |