| NPI | 1861761538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: OH 35.128128) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2011-12-23 |
| Last Update Date | 2017-04-25 |