| NPI | 1548766082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MA 1016149) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2086S0129X (Licence: MA 1016149) | |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2026-07-27 |