| NPI | 1134594245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2015-12-01 |
| Last Update Date | 2020-06-18 |