| NPI | 1629488960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: OH 35.143016) |
| Additional Taxonomies | 208600000X Surgery (Licence: TX BP10050789) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 35.143016) | |
| Enumeration Date | 2014-05-07 |
| Last Update Date | 2025-04-03 |