| NPI | 1457089088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: PA MD491330) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT224926) |
| Enumeration Date | 2022-08-11 |
| Last Update Date | 2026-02-23 |