| NPI | 1396599106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: OH 34.018179) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 58.034243) |
| Enumeration Date | 2024-04-16 |
| Last Update Date | 2025-09-25 |