| NPI | 1881198182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA 3015045) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA A163798) |
| Enumeration Date | 2018-03-21 |
| Last Update Date | 2023-06-29 |