| NPI | 1952751315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2018-02509) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 5101022678) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 2018-02509) | |
| Enumeration Date | 2016-06-16 |
| Last Update Date | 2025-08-18 |