| NPI | 1790449882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2021-10-26 |
| Last Update Date | 2022-06-15 |