| NPI | 1700128154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: UT 9178686-1205) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2085R0001X (Licence: CO DR.0060291) | |
| Enumeration Date | 2013-03-25 |
| Last Update Date | 2026-06-15 |