| NPI | 1043247091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman (Licence: AZ 2099) |
| Additional Taxonomies | 174400000X Specialist |
| 171000000X Military Health Care Provider (Licence: CA 2099) | |
| Enumeration Date | 2006-06-26 |
| Last Update Date | 2008-04-22 |