| NPI | 1154687531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: OH 35C.002926) |
| Additional Taxonomies | 2086S0129X (Licence: MD D0095204) |
| 2086S0129X (Licence: PA MD478869) | |
| 2086S0129X (Licence: PA FC1854860) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-04-10 |
| Last Update Date | 2025-10-07 |