| NPI | 1205214665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080H0002X (Licence: NY 297842) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: CT 61407) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-05-18 |
| Last Update Date | 2020-06-14 |