| NPI | 1790219251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080P0006X Pediatrics, Developmental - Behavioral Pediatrics (Licence: OH 34.014459) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-04-11 |
| Last Update Date | 2023-07-03 |