| NPI | 1831401728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: UT 13828790-1205) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208600000X Surgery (Licence: MN 63566) | |
| Enumeration Date | 2010-07-08 |
| Last Update Date | 2024-02-21 |