| NPI | 1427443597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MD490375) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MD D82448) |
| Enumeration Date | 2015-04-05 |
| Last Update Date | 2025-08-14 |