| NPI | 1962004838 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: CA E3223966) |
| 183700000X Pharmacy Technician (Licence: TX 30045107) | |
| Enumeration Date | 2020-11-14 |
| Last Update Date | 2022-07-12 |