| NPI | 1629236260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX P7191) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN12331) |
| Enumeration Date | 2008-05-30 |
| Last Update Date | 2017-10-20 |