| NPI | 1902268931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080P0008X Pediatrics, Neurodevelopmental Disabilities (Licence: LA 330161) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2016-03-29 |
| Last Update Date | 2022-08-22 |