| NPI | 1366977415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: SC 91231) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2086S0129X (Licence: CT 71828) | |
| Enumeration Date | 2017-04-26 |
| Last Update Date | 2024-08-16 |