| NPI | 1184072860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085N0700X (Licence: AZ 007300) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2085N0700X (Licence: NV CL0716) | |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2025-08-01 |