| NPI | 1962721738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MA 273699) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: MN 54925) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-05-19 |
| Last Update Date | 2019-04-08 |