| NPI | 1790121374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0120X Surgery, Pediatric Surgery (Licence: OR MD216477) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301102983) |
| Enumeration Date | 2013-05-22 |
| Last Update Date | 2023-07-27 |