| NPI | 1396301602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: TX U9878) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX U9878) |
| Enumeration Date | 2019-05-13 |
| Last Update Date | 2024-08-01 |