| NPI | 1619916186 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 246QM0706X Spec/Tech, Pathology, Medical Technologist |
| Enumeration Date | 2006-06-06 |
| Last Update Date | 2021-08-12 |