| NPI | 1184052474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208800000X Urology (Licence: FL ME175927) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT205038) |
| Enumeration Date | 2013-10-23 |
| Last Update Date | 2026-08-17 |