| NPI | 1942696752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: NY 335706) |
| Additional Taxonomies | 2085R0001X (Licence: MA 283849) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-04-08 |
| Last Update Date | 2025-04-24 |