| NPI | 1124468277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX S5141) |
| Additional Taxonomies | 208600000X Surgery (Licence: FL ME159414) |
| 208600000X Surgery (Licence: MA 285974) | |
| Enumeration Date | 2013-07-02 |
| Last Update Date | 2025-02-13 |