| NPI | 1902290596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: PA MD483302) |
| Additional Taxonomies | 208600000X Surgery (Licence: NE 29517) |
| 171000000X Military Health Care Provider (Licence: NE 29517) | |
| 2086S0120X Surgery, Pediatric Surgery (Licence: MA 286672) | |
| Enumeration Date | 2015-03-23 |
| Last Update Date | 2023-12-08 |