| NPI | 1730388976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: LA DO.000426) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208600000X Surgery (Licence: GA 62821) | |
| Enumeration Date | 2007-07-17 |
| Last Update Date | 2025-05-14 |