| NPI | 1891572533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: IL 125086179) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125.086179) |
| Enumeration Date | 2023-09-14 |
| Last Update Date | 2025-08-05 |