| NPI | 1972906915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251V00000X Voluntary or Charitable |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MD 03QY679) |
| Enumeration Date | 2014-10-05 |
| Last Update Date | 2014-10-05 |