| NPI | 1760902639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NV 24300) |
| Additional Taxonomies | 208600000X Surgery (Licence: RI LP03965) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT219493) | |
| Enumeration Date | 2017-06-22 |
| Last Update Date | 2023-09-28 |