| NPI | 1376070748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208800000X Urology (Licence: VA 0101282291) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA A157160) |
| Enumeration Date | 2017-05-17 |
| Last Update Date | 2024-08-08 |