| NPI | 1639438567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: TX W6491) |
| Additional Taxonomies | 208600000X Surgery (Licence: WA 60897037) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2012-05-13 |
| Last Update Date | 2026-09-08 |