| NPI | 1649970799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 156F00000X Technician/Technologist (Licence: PA 2674850) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-03-07 |
| Last Update Date | 2023-03-07 |