| NPI | 1871758029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WI 56746-20) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WI 56746-20) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MO 2008021980) | |
| Enumeration Date | 2008-07-26 |
| Last Update Date | 2018-04-02 |