| NPI | 1104802669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 146N00000X Emergency Medical Technician, Basic (Licence: MA B1673133) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MA B1673133) |
| Enumeration Date | 2005-12-16 |
| Last Update Date | 2025-09-11 |