| NPI | 1659663557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MN 58335) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208000000X Pediatrics (Licence: ND 13334) | |
| Enumeration Date | 2011-05-10 |
| Last Update Date | 2015-04-27 |