| NPI | 1578809794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CA 20A15770) |
| Additional Taxonomies | 208600000X Surgery (Licence: ME DO3105) |
| 208600000X Surgery (Licence: NH 22416) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-12-14 |
| Last Update Date | 2022-07-21 |