| NPI | 1578903589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102204036) |
| Additional Taxonomies | 208800000X Urology (Licence: VA 0102204036) |
| Enumeration Date | 2013-07-05 |
| Last Update Date | 2024-12-10 |