| NPI | 1366769721 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health (Licence: FL 11015496) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2341878) |
| 1710I1002X Military Health Care Provider Independent Duty Corpsman | |
| Enumeration Date | 2010-04-26 |
| Last Update Date | 2022-04-27 |