| NPI | 1811230220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NE 1247) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: NE 1247) | |
| Enumeration Date | 2013-04-03 |
| Last Update Date | 2024-03-07 |