| NPI | 1578258497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084P0805X (Licence: VA 0116037947) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2023-04-06 |
| Last Update Date | 2025-06-17 |