| NPI | 1164408464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2007-07-08 |