| NPI | 1457083479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: HI DOSR-708) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NV SL1894) |
| Enumeration Date | 2022-06-28 |
| Last Update Date | 2026-06-15 |