NPI | 1639614399 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102205357) |
Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
Enumeration Date | 2017-01-04 |
Last Update Date | 2020-10-20 |