| NPI | 1053796417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: UT 12326760-1205) |
| Additional Taxonomies | 208600000X Surgery (Licence: CA A149173) |
| Enumeration Date | 2015-07-28 |
| Last Update Date | 2021-08-25 |