| NPI | 1689314544 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 208000000X Pediatrics (Licence: OR DO226698) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2022-03-30 | 
| Last Update Date | 2025-10-24 |