| NPI | 1366768681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MA 244808) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: MA 244808) | |
| Enumeration Date | 2010-04-12 |
| Last Update Date | 2012-08-07 |