| NPI | 1568213668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 57.256586) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: OH 57.256586) |
| Enumeration Date | 2024-03-28 |
| Last Update Date | 2025-08-15 |