| NPI | 1962145730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 175T00000X Peer Specialist (Licence: WY 127) | |
| Enumeration Date | 2022-04-19 |
| Last Update Date | 2026-06-30 |