| NPI | 1548905060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: SC 92613) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-04-29 |
| Last Update Date | 2025-04-30 |