| NPI | 1558252924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians (Licence: IN 3251-2416-8453) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman (Licence: IN 3521-2416-8453) |
| 207P00000X Emergency Medicine (Licence: IN 30018103) | |
| Enumeration Date | 2025-07-14 |
| Last Update Date | 2025-10-28 |