| NPI | 1821670639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KY 62321) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: KY 62321) | |
| Enumeration Date | 2021-04-22 |
| Last Update Date | 2026-07-28 |