| NPI | 1043449762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: MD D80350) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2085R0001X (Licence: PA MD454486) | |
| Enumeration Date | 2009-07-02 |
| Last Update Date | 2015-11-30 |