| NPI | 1356961767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2083A0100X Preventive Medicine Aerospace Medicine (Licence: VA 0102207089) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider (Licence: VA 0102207089) | |
| Enumeration Date | 2020-04-26 |
| Last Update Date | 2023-10-23 |