| NPI | 1205951720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NC 2007-00739) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: MI 4301083781) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301083781) | |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2007-10-11 |