| NPI | 1982131645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101265264) |
| Enumeration Date | 2017-05-12 |
| Last Update Date | 2022-05-17 |