| NPI | 1760936678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: WV 28834) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP1-0056065) |
| Enumeration Date | 2016-08-09 |
| Last Update Date | 2022-04-06 |