| NPI | 1366202111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 286500000X Military Hospital | |
| Enumeration Date | 2024-03-20 |
| Last Update Date | 2024-07-02 |