| NPI | 1619354040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: SC 84159) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2015-05-06 |
| Last Update Date | 2023-03-23 |