| NPI | 1376923466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: OH 34.014692) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2085R0001X (Licence: MI 5101025662) | |
| 2085R0001X (Licence: NY 325759) | |
| Enumeration Date | 2015-06-03 |
| Last Update Date | 2025-11-17 |