| NPI | 1104544089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2022-08-17 |
| Last Update Date | 2023-02-14 |