| NPI | 1396029559 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| Enumeration Date | 2011-10-06 |
| Last Update Date | 2026-07-20 |