| NPI | 1134709926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 35.147433) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: OH 57.251003) |
| Enumeration Date | 2021-04-14 |
| Last Update Date | 2023-03-05 |