| NPI | 1508506783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116041626) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: SC LL87699) |
| 207R00000X Internal Medicine (Licence: SC LL87699) | |
| Enumeration Date | 2022-03-29 |
| Last Update Date | 2026-06-15 |