| NPI | 1720493505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 150561.) |
| Additional Taxonomies | 208600000X Surgery (Licence: MA 268932) |
| Enumeration Date | 2014-06-30 |
| Last Update Date | 2021-05-31 |