| NPI | 1063852192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CO CDR.0000125) |
| Additional Taxonomies | 208600000X Surgery (Licence: FL ME116123) |
| Enumeration Date | 2013-07-03 |
| Last Update Date | 2018-07-19 |