| NPI | 1477973923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MS T-6166) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MS T-6166) |
| Enumeration Date | 2014-04-23 |
| Last Update Date | 2026-07-13 |