| NPI | 1346738648 |
|---|---|
| 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: VA 0102205823) |
| Enumeration Date | 2018-04-23 |
| Last Update Date | 2023-06-06 |