| NPI | 1164620480 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: WI 61061) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 4301090378) |
| 208600000X Surgery (Licence: MA 250712) | |
| 208600000X Surgery (Licence: IA 41119) | |
| Enumeration Date | 2007-07-08 |
| Last Update Date | 2014-03-24 |