| NPI | 1861783938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX R9083) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 277205) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-04-25 |
| Last Update Date | 2023-06-12 |