| NPI | 1740609056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MI 4301508469) |
| Additional Taxonomies | 208600000X Surgery (Licence: OH 35.135578) |
| 208600000X Surgery (Licence: GA 82672) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-04-15 |
| Last Update Date | 2022-12-09 |