| NPI | 1144546821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: OK 34692) |
| Additional Taxonomies | 208600000X Surgery (Licence: FL ME132959) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2010-04-20 |
| Last Update Date | 2019-05-13 |