| NPI | 1003073602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0116015702) |
| Additional Taxonomies | 261QM1300X Clinic/Center Multi-Specialty |
| Enumeration Date | 2008-05-21 |
| Last Update Date | 2022-01-31 |