| NPI | 1467652644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic |
| Enumeration Date | 2007-07-25 |
| Last Update Date | 2007-07-25 |