| NPI | 1053638734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: NC 03534) |
| Additional Taxonomies | 2086S0129X (Licence: SC 97267) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 2086S0129X (Licence: KY 50119) | |
| Enumeration Date | 2010-04-21 |
| Last Update Date | 2026-07-14 |