| NPI | 1487093969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: OR MD192028) |
| Additional Taxonomies | 261QP2300X Clinic/Center Primary Care (Licence: MN 61589) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-06-18 |
| Last Update Date | 2022-03-25 |