| NPI | 1023334158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2010-04-14 |
| Last Update Date | 2015-10-08 |