| NPI | 1124559836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: PA MT222045) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10059163) |
| Enumeration Date | 2017-03-23 |
| Last Update Date | 2020-09-01 |