| NPI | 1215558671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085N0700X (Licence: WA MD.MD.61679485) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2020-04-27 |
| Last Update Date | 2025-06-10 |