| NPI | 1720643455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: CT 75763) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-05-08 |
| Last Update Date | 2025-06-10 |