| NPI | 1497103832 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: GA 105400) |
| Additional Taxonomies | 2086S0129X (Licence: IL 036.165202) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301109412) | |
| Enumeration Date | 2016-05-26 |
| Last Update Date | 2025-07-24 |