| NPI | 1669736427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WV 29592) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 4301101553) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-06-26 |
| Last Update Date | 2021-11-17 |