| NPI | 1457745093 |
|---|---|
| Professional Name | NA NA NA |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME158216) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: MD d0085188) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-03-21 |
| Last Update Date | 2022-10-12 |