| NPI | 1326629080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NC 2022-01998) |
| 208D00000X General Practice (Licence: GA 2022-01998) | |
| Enumeration Date | 2021-04-15 |
| Last Update Date | 2025-07-28 |