| NPI | 1164555272 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MO 2020029424) |
| Additional Taxonomies | 208600000X Surgery (Licence: DE C7-0002988) |
| 208600000X Surgery (Licence: FL ME 112305) | |
| 208600000X Surgery (Licence: NY 252285-1) | |
| Enumeration Date | 2007-03-14 |
| Last Update Date | 2021-12-01 |