| NPI | 1811351406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX T7945) |
| Additional Taxonomies | 208600000X Surgery (Licence: MA 1016828) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-04-08 |
| Last Update Date | 2023-11-13 |