| NPI | 1265060073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: FL ME183387) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2085R0001X (Licence: OH 35.154369) | |
| Enumeration Date | 2020-03-28 |
| Last Update Date | 2026-08-31 |