| NPI | 1225425374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX T8319) |
| Additional Taxonomies | 208600000X Surgery (Licence: FL ME149028) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-04-15 |
| Last Update Date | 2023-05-01 |