| NPI | 1114129558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WA OP60097299) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 5101 016273) |
| Enumeration Date | 2007-06-05 |
| Last Update Date | 2012-11-15 |