| NPI | 1083369938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians (Licence: TX L5ALJ4N051C00AB) |
| Enumeration Date | 2022-02-18 |
| Last Update Date | 2022-08-02 |