NPI | 1063783850 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102203534) |
Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
Enumeration Date | 2012-01-25 |
Last Update Date | 2022-09-09 |