| NPI | 1063945772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: SC 93041) |
| Additional Taxonomies | 207T00000X Neurological Surgery (Licence: SC 93041) |
| Enumeration Date | 2017-04-10 |
| Last Update Date | 2025-05-09 |