| NPI | 1154196806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085N0904X (Licence: GA 15857) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2023-11-21 |
| Last Update Date | 2025-04-26 |