| NPI | 1316649577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC MINN-0XREIL) |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2023-03-28 |