| NPI | 1114473097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: PR 021264) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT214392) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-08-30 |
| Last Update Date | 2021-11-11 |