| 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 |