| NPI | 1174054696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2024-01410) |
| Additional Taxonomies | 208600000X Surgery (Licence: VA 0101279296) |
| 208600000X Surgery (Licence: SC 94178) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-03-26 |
| Last Update Date | 2025-06-25 |