| NPI | 1265965230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2025-03042) |
| Additional Taxonomies | 208600000X Surgery (Licence: NC 240013) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-04-06 |
| Last Update Date | 2025-11-11 |