| NPI | 1508398587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman (Licence: AL 37520) |
| 208D00000X General Practice (Licence: AL 37520) | |
| Enumeration Date | 2017-03-30 |
| Last Update Date | 2023-07-24 |