| NPI | 1063728053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0102X Surgery, Surgical Critical Care (Licence: NE 26409) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 26409) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 202D00000X Integrative Medicine (Licence: NE 26409) | |
| Enumeration Date | 2010-08-27 |
| Last Update Date | 2026-04-06 |