| NPI | 1326193947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 17473) |
| Additional Taxonomies | 111NX0800X Chiropractor Orthopedic (Licence: GA CHIRO 007809) |
| 363AM0700X Physician Assistant Medical (Licence: GA 003324) | |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2025-09-30 |