| NPI | 1235714064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 57.251634) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-03-12 |
| Last Update Date | 2023-03-02 |