| NPI | 1023142817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CO 37393) |
| Additional Taxonomies | 208600000X Surgery (Licence: AL 3542) |
| 208600000X Surgery (Licence: WY 3235A) | |
| 208600000X Surgery (Licence: MT 8440) | |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2009-08-13 |