| NPI | 1881199404 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116037501) | 
| Additional Taxonomies | 2086S0129X (Licence: CO DR.0074857) | 
| Enumeration Date | 2018-03-26 | 
| Last Update Date | 2025-09-16 |