| NPI | 1316756190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: 1321-1450-4619) |
| Enumeration Date | 2025-01-06 |
| Last Update Date | 2025-09-08 |