| NPI | 1104168582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NM MD2019-0664) |
| Additional Taxonomies | 208600000X Surgery (Licence: WV 27993) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-03-22 |
| Last Update Date | 2023-07-10 |