| NPI | 1265961908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: NY 313938) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-06-07 |
| Last Update Date | 2022-07-14 |