| NPI | 1174819593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: WA MD60992584) |
| Additional Taxonomies | 208600000X Surgery (Licence: MN 60567) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-06-23 |
| Last Update Date | 2025-06-09 |