| NPI | 1902840606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: NM MD2014-0874) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: IN 01056629A) |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2025-07-29 |