| NPI | 1336727718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX W1726) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: KY 58542) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-29 |
| Last Update Date | 2026-06-25 |