| NPI | 1922539980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101265270) |
| 208D00000X General Practice (Licence: VA 0101265270) | |
| Enumeration Date | 2017-03-22 |
| Last Update Date | 2022-09-03 |