| NPI | 1114459831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: CO DR.0070712) |
| Additional Taxonomies | 2086S0129X (Licence: AZ 80796) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-03-31 |
| Last Update Date | 2026-05-18 |