| NPI | 1912296740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MO 2014010845) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: N/A) |
| Enumeration Date | 2011-04-01 |
| Last Update Date | 2014-09-11 |