| NPI | 1528564606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 174400000X Specialist |
| 261QP0905X Clinic/Center, Public Health, State or Local | |
| Enumeration Date | 2018-04-05 |
| Last Update Date | 2024-12-11 |