| NPI | 1689136590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: MA 1019775) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2019-04-01 |
| Last Update Date | 2025-08-24 |