| NPI | 1417417361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WV ED1254) |
| Additional Taxonomies | 172V00000X Community Health Worker |
| Enumeration Date | 2019-03-25 |
| Last Update Date | 2026-02-27 |