| NPI | 1043409162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: CA 1151164) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2007-10-15 |
| Last Update Date | 2021-02-23 |