| NPI | 1154736437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 267056) |
| Additional Taxonomies | 208600000X Surgery (Licence: GA 74379) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-06-25 |
| Last Update Date | 2025-03-13 |