| NPI | 1588870323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: OH 35.097860) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT188837) |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2011-08-30 |