| NPI | 1568046258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 261QS1000X Clinic/Center Student Health |
| Enumeration Date | 2021-05-08 |
| Last Update Date | 2022-04-19 |