| NPI | 1609335009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208800000X Urology (Licence: VA 0101270234) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101270234) |
| Enumeration Date | 2019-03-15 |
| Last Update Date | 2026-07-03 |