| NPI | 1629275920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164X00000X Licensed Vocational Nurse (Licence: CA 165116) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2013-07-24 |