| NPI | 1245792332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: LA 0002105974) |
| Enumeration Date | 2019-04-05 |
| Last Update Date | 2025-11-07 |