| NPI | 1740556174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080N0001X Pediatrics, Neonatal-Perinatal Medicine (Licence: CT 83379) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2012-03-29 |
| Last Update Date | 2026-05-21 |