| NPI | 1396150306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208800000X Urology (Licence: MI 4301504091) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208800000X Urology (Licence: VA 0101269448) | |
| Enumeration Date | 2014-06-27 |
| Last Update Date | 2026-05-29 |