| NPI | 1912396730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 246ZS0410X Specialist/Technologist, Other, Surgical Technologist |
| Enumeration Date | 2015-01-16 |
| Last Update Date | 2015-01-16 |