| NPI | 1861871899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208200000X Plastic Surgery (Licence: CA 180594) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2015-05-22 |
| Last Update Date | 2025-08-15 |