| NPI | 1215732565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2025-02-19 |
| Last Update Date | 2025-02-19 |