| NPI | 1174373146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NC RTL24-0535) |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: NC RTL24-0535) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: Ulrich3795) | |
| Enumeration Date | 2024-03-25 |
| Last Update Date | 2024-07-09 |