| NPI | 1528742681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NE 2958) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10086146) |
| Enumeration Date | 2023-06-09 |
| Last Update Date | 2025-11-18 |