| NPI | 1417215120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: TX R2225) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10044259) |
| Enumeration Date | 2012-05-01 |
| Last Update Date | 2019-06-25 |