| NPI | 1063838159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA A155768) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA A155768) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-03-13 |
| Last Update Date | 2020-03-25 |