| NPI | 1639457856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: WI 60654) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2011-07-22 |
| Last Update Date | 2014-06-10 |