| NPI | 1083174734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085N0700X (Licence: NY 308958) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2019-03-20 |
| Last Update Date | 2025-08-06 |