| NPI | 1427631209 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2023-01176) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-04-30 |
| Last Update Date | 2026-06-24 |