| NPI | 1164715975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2020-02309) |
| Additional Taxonomies | 208600000X Surgery (Licence: MO 2012016753) |
| Enumeration Date | 2011-05-26 |
| Last Update Date | 2023-07-27 |