| NPI | 1700387578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101268149) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-02-26 |
| Last Update Date | 2024-08-29 |