| NPI | 1386103661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: NV 25678) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2085R0001X (Licence: AZ 76667) | |
| Enumeration Date | 2019-03-17 |
| Last Update Date | 2026-04-14 |