| NPI | 1942825567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: KY 60838) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2020-06-09 |
| Last Update Date | 2025-06-30 |