| NPI | 1326459603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: IA MD-47179) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208600000X Surgery (Licence: MI 43510330838) | |
| 208600000X Surgery (Licence: IL 036168680) | |
| Enumeration Date | 2014-05-08 |
| Last Update Date | 2025-08-21 |