| NPI | 1487935508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NY 291728) |
| Additional Taxonomies | 208600000X Surgery (Licence: MN TP107185) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-09-01 |
| Last Update Date | 2018-03-17 |