| NPI | 1063974319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207XX0005X Orthopaedic Surgery, Sports Medicine (Licence: NC 2026-04253) |
| Additional Taxonomies | 207X00000X Orthopaedic Surgery (Licence: LA 345088) |
| Enumeration Date | 2019-04-04 |
| Last Update Date | 2026-07-23 |