| NPI | 1780278077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 35.147661) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-02-26 |
| Last Update Date | 2023-04-07 |