| NPI | 1003804964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NJ 25MA08240200) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MD068352L) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2016-01-27 |