| NPI | 1730405143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: WI 6435320) |
| Additional Taxonomies | 2085R0001X (Licence: HI 19198) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-04-09 |
| Last Update Date | 2021-03-30 |