| NPI | 1639379274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MI 4301089480) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301089480) |
| Enumeration Date | 2007-07-23 |
| Last Update Date | 2021-04-01 |