| NPI | 1558033159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: E3540136) |
| Enumeration Date | 2021-10-01 |
| Last Update Date | 2024-06-03 |