| NPI | 1720216898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: MO 2011003946) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2009-06-29 |
| Last Update Date | 2020-06-08 |