| NPI | 1215468954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NY 304206) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-03-24 |
| Last Update Date | 2021-01-14 |