| NPI | 1679514392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: GA RN283456) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider Independent Duty Corpsman |
| Enumeration Date | 2006-06-10 |
| Last Update Date | 2023-03-15 |