| NPI | 1487278545 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: MI 4301514068) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA ETLL-958) |
| Enumeration Date | 2020-06-04 |
| Last Update Date | 2025-06-27 |