| NPI | 1891152740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102204956) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2016-01-23 |
| Last Update Date | 2021-07-22 |