| NPI | 1114371549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: FL ME168903) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2016-04-22 |
| Last Update Date | 2026-08-20 |