| NPI | 1902290596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0120X Surgery, Pediatric Surgery (Licence: MA 286672) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 29517) |
| 208600000X Surgery (Licence: NE 29517) | |
| 208600000X Surgery (Licence: PA MD483302) | |
| Enumeration Date | 2015-03-23 |
| Last Update Date | 2024-08-25 |