| NPI | 1932767712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: CO 0075374) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NE 2339) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2019-06-05 |
| Last Update Date | 2025-06-26 |