| NPI | 1659722296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME139596) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN23477) |
| Enumeration Date | 2016-06-24 |
| Last Update Date | 2019-07-02 |