| NPI | 1114243664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: FL ME139606) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 286418) |
| 208600000X Surgery (Licence: OH 35.098974) | |
| Enumeration Date | 2010-04-08 |
| Last Update Date | 2019-06-20 |