| NPI | 1104053065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208800000X Urology (Licence: NY 279506) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT013043) |
| 208800000X Urology (Licence: MD H0077362) | |
| Enumeration Date | 2009-06-18 |
| Last Update Date | 2015-08-31 |