| NPI | 1124559935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NY 319740) |
| Additional Taxonomies | 261Q00000X Clinic/Center |
| 261Q00000X Clinic/Center (Licence: NY 319740) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-03-23 |
| Last Update Date | 2022-10-18 |