| NPI | 1558999458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207L00000X Anesthesiology (Licence: IL 125.081201) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: NC 2021-02554) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-03-28 |
| Last Update Date | 2023-05-31 |