| NPI | 1154010981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX 1154010981) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-05-08 |
| Last Update Date | 2025-09-29 |