| NPI | 1114507670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: SC 86191) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: SC LL86191) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-09 |
| Last Update Date | 2025-03-07 |