| NPI | 1861464513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208800000X Urology (Licence: WA MD60276697) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MD D0060759) |
| Enumeration Date | 2006-02-06 |
| Last Update Date | 2013-01-31 |