| NPI | 1063819621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: CT 168088) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2014-11-25 |
| Last Update Date | 2021-12-30 |