| NPI | 1124783733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0131X (Licence: TX 692233) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2021-11-08 |
| Last Update Date | 2026-03-06 |