| NPI | 1164632931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 37550) |
| Additional Taxonomies | 208600000X Surgery (Licence: MA 233642) |
| 208600000X Surgery (Licence: VA 0101249818) | |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2015-06-08 |