| NPI | 1881806446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: WI 50259-020) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WI 50259) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT 184726) | |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2021-06-14 |