| NPI | 1710322193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: VA 0101271094) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MT204481) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-04-30 |
| Last Update Date | 2022-02-04 |