| NPI | 1578181772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MA 1026450) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208000000X Pediatrics (Licence: PR 24512) | |
| 208D00000X General Practice (Licence: PR 24512) | |
| Enumeration Date | 2020-07-14 |
| Last Update Date | 2026-06-16 |