| NPI | 1720742877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman (Licence: CA 1720742877) |
| Enumeration Date | 2021-10-25 |
| Last Update Date | 2025-10-12 |