| NPI | 1952716979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: LA 326682) |
| Additional Taxonomies | 208C00000X Colon & Rectal Surgery (Licence: LA 326682) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: GA 7260) | |
| Enumeration Date | 2014-06-27 |
| Last Update Date | 2021-08-04 |