| NPI | 1992199467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: WA MD61441574) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 29874) |
| 208600000X Surgery (Licence: NE 29874) | |
| 208600000X Surgery (Licence: TX T8816) | |
| Enumeration Date | 2015-03-23 |
| Last Update Date | 2023-05-16 |