| NPI | 1285153825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102205755) |
| Additional Taxonomies | 286500000X Military Hospital |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-09-14 |
| Last Update Date | 2020-04-05 |