| NPI | 1043579808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CA A121235) |
| Additional Taxonomies | 208600000X Surgery (Licence: UT 14218149-1205) |
| Enumeration Date | 2012-05-14 |
| Last Update Date | 2025-05-28 |