| NPI | 1215370531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101269782) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 300147-01) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-04-17 |
| Last Update Date | 2021-03-08 |