| NPI | 1609258763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208VP0000X (Licence: AZ 58107) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IN 11018489A) |
| Enumeration Date | 2015-06-25 |
| Last Update Date | 2019-07-05 |