| NPI | 1558749598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NC 210624) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 210624) |
| Enumeration Date | 2015-05-11 |
| Last Update Date | 2020-09-08 |