| NPI | 1356086664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0101279453) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0101279453) | |
| Enumeration Date | 2022-05-02 |
| Last Update Date | 2023-12-07 |