| NPI | 1780304378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1100X Clinic/Center Military/U.S. Coast Guard Outpatient |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2022-09-01 |
| Last Update Date | 2023-02-20 |