| NPI | 1891174504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208800000X Urology (Licence: WI 81651) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208800000X Urology (Licence: CA A203808) | |
| Enumeration Date | 2015-05-27 |
| Last Update Date | 2025-08-04 |