| NPI | 1598108672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2018-01458) |
| Additional Taxonomies | 208600000X Surgery (Licence: WA ML60361281) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA TBD) | |
| Enumeration Date | 2013-04-09 |
| Last Update Date | 2021-03-24 |