| NPI | 1245217769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208800000X Urology (Licence: WI 34673-20) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101233888) |
| Enumeration Date | 2005-12-27 |
| Last Update Date | 2015-05-13 |