| NPI | 1720425424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208800000X Urology (Licence: VA 0101257215) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208600000X Surgery (Licence: AZ R74100) | |
| Enumeration Date | 2013-06-04 |
| Last Update Date | 2026-05-20 |