| NPI | 1851500201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX P2826) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116018689) |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2019-07-31 |