| NPI | 1033191200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MN 60101) |
| Additional Taxonomies | 208600000X Surgery (Licence: CA A88529) |
| 208600000X Surgery (Licence: KY 43356) | |
| 207Q00000X Family Medicine (Licence: KY 43356) | |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2021-12-13 |