| NPI | 1205086030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: MA 260516) |
| Additional Taxonomies | 2086S0129X (Licence: NH 22542) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2008-09-29 |
| Last Update Date | 2026-01-20 |