| NPI | 1073253308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: OH 57.259396) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116037507) |
| Enumeration Date | 2022-04-01 |
| Last Update Date | 2025-09-16 |