| NPI | 1508919804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MN 60575) |
| Additional Taxonomies | 208600000X Surgery (Licence: MD D0059271) |
| 208600000X Surgery (Licence: VA 0101239675) | |
| 208600000X Surgery (Licence: NM MD2012-0683) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM MD2012-0683) | |
| Enumeration Date | 2007-01-19 |
| Last Update Date | 2022-07-21 |