| NPI | 1841635836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 1841635836) |
| Enumeration Date | 2013-05-03 |
| Last Update Date | 2021-04-20 |