| NPI | 1013145697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: UT 9743925-1204) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208600000X Surgery (Licence: NC 2015-02260) | |
| Enumeration Date | 2009-06-23 |
| Last Update Date | 2019-04-03 |