| NPI | 1558942276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2952000753) | |
| Enumeration Date | 2021-04-15 |
| Last Update Date | 2024-06-22 |