| NPI | 1235485145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX R7425) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL ME123643) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN17354) | |
| Enumeration Date | 2012-07-29 |
| Last Update Date | 2020-10-13 |