| NPI | 1295398071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: GA 93496) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208000000X Pediatrics (Licence: WI 82241-21) | |
| Enumeration Date | 2019-04-17 |
| Last Update Date | 2026-06-23 |