| NPI | 1295025765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX T5532) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 32740) |
| 208600000X Surgery (Licence: OK 32740) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 63064) | |
| Enumeration Date | 2011-04-18 |
| Last Update Date | 2022-12-07 |