| NPI | 1134576390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2016-05-18 |
| Last Update Date | 2025-01-31 |