| NPI | 1346680790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NY 293644) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: NY 293644) | |
| Enumeration Date | 2013-06-30 |
| Last Update Date | 2020-09-10 |