| NPI | 1912135583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NJ 25MA09882200) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: ZZ G-40452) |
| Enumeration Date | 2009-06-23 |
| Last Update Date | 2016-11-23 |