| NPI | 1184004707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: AZ 67629) |
| Additional Taxonomies | 2086S0120X Surgery, Pediatric Surgery (Licence: MT 165987) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2015-06-09 |
| Last Update Date | 2026-06-30 |