| NPI | 1639136922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: WA MD60037735) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: WI 1694) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 49787) | |
| Enumeration Date | 2006-04-28 |
| Last Update Date | 2018-06-29 |