| NPI | 1902221419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: VA 0101258740) |
| Additional Taxonomies | 208600000X Surgery (Licence: WV 28622) |
| 208600000X Surgery (Licence: VA 0101258740) | |
| 208D00000X General Practice (Licence: VA 0101258740) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-02-20 |
| Last Update Date | 2025-08-07 |