| NPI | 1154611929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: FL ME137415) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 286161) |
| 208600000X Surgery (Licence: WA MD60714287) | |
| 208600000X Surgery (Licence: CT 55635) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-04-14 |
| Last Update Date | 2018-08-01 |