| NPI | 1205276789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME127805) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN18747) |
| Enumeration Date | 2013-06-28 |
| Last Update Date | 2019-04-26 |