| NPI | 1215270301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TN 57177) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208600000X Surgery (Licence: NE 31035) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-03-27 |
| Last Update Date | 2018-10-03 |