| NPI | 1477006591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: ID 9271076) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 4301512108) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 208600000X Surgery (Licence: PA MT213958) | |
| Enumeration Date | 2016-07-25 |
| Last Update Date | 2025-10-28 |