| NPI | 1811308257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101268393) |
| Additional Taxonomies | 208600000X Surgery (Licence: AL 34727) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2014-05-19 |
| Last Update Date | 2024-01-17 |