| NPI | 1184299810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NE 2677) |
| Additional Taxonomies | 208600000X Surgery (Licence: SC 83594) |
| Enumeration Date | 2021-05-25 |
| Last Update Date | 2023-09-19 |