| NPI | 1578857371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101253472) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2011-06-09 |
| Last Update Date | 2018-04-26 |