| NPI | 1457503930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: PR 17310) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 17310) |
| Enumeration Date | 2008-10-16 |
| Last Update Date | 2016-09-16 |