| NPI | 1114000130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 247200000X Technician, Other |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2013-10-08 |