| NPI | 1861292120 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 286500000X Military Hospital |
| Enumeration Date | 2025-03-17 |
| Last Update Date | 2025-03-17 |