| NPI | 1790964385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX R0201) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NJ 25MA08693400) |
| 2080N0001X Pediatrics, Neonatal-Perinatal Medicine (Licence: NJ 25MA08693400) | |
| 261QP2300X Clinic/Center, Primary Care (Licence: NJ 25MA08693400) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: #39) | |
| Enumeration Date | 2007-10-31 |
| Last Update Date | 2020-10-29 |