| NPI | 1053574780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207XX0005X Orthopaedic Surgery, Sports Medicine (Licence: VA 0101246282) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101246282) |
| Enumeration Date | 2008-07-02 |
| Last Update Date | 2019-01-29 |