| NPI | 1063143402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: 57.252363) |
| Additional Taxonomies | 208600000X Surgery (Licence: OH 57.252363) |
| Enumeration Date | 2022-06-17 |
| Last Update Date | 2022-07-01 |