| NPI | 1578064515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC RTL23-0768) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102205774) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-02-26 |
| Last Update Date | 2023-06-01 |