| NPI | 1396301602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: TX U9878) |
| Additional Taxonomies | 208600000X Surgery (Licence: CA A207392) |
| 171000000X Military Health Care Provider (Licence: TX U9878) | |
| Enumeration Date | 2019-05-13 |
| Last Update Date | 2026-04-22 |