| NPI | 1396861936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: MI 4301087851) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301087851) |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2026-06-15 |