| NPI | 1952752198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101263734) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101263734) |
| Enumeration Date | 2016-06-29 |
| Last Update Date | 2023-10-24 |