| NPI | 1255910741 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084N0600X (Licence: UT 14217006-1205) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2021-04-03 |
| Last Update Date | 2025-06-13 |