| NPI | 1568782928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207L00000X Anesthesiology (Licence: NC 2024-01230) |
| Additional Taxonomies | 207L00000X Anesthesiology (Licence: WV 24524) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WV 39020000x) | |
| Enumeration Date | 2010-06-08 |
| Last Update Date | 2024-09-17 |