| NPI | 1477715241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: IN 01068565A) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125055127) |
| Enumeration Date | 2008-07-01 |
| Last Update Date | 2025-09-30 |