| NPI | 1669918322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL C462805953320) |
| Enumeration Date | 2017-01-18 |
| Last Update Date | 2024-05-01 |