| NPI | 1568046258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 343802-01) |
| Additional Taxonomies | 261QS1000X Clinic/Center, Student Health (Licence: NY 343802-01) |
| Enumeration Date | 2021-05-08 |
| Last Update Date | 2026-08-26 |