| NPI | 1720493505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0120X Surgery, Pediatric Surgery (Licence: FL ME150561) |
| Additional Taxonomies | 208600000X Surgery (Licence: MA 268932) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 150561.) | |
| Enumeration Date | 2014-06-30 |
| Last Update Date | 2025-08-20 |