| NPI | 1750058046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman (Licence: CA 1750058046) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2021-08-25 |
| Last Update Date | 2022-02-14 |