| NPI | 1174508865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CA G88950) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 184876) |
| 208600000X Surgery (Licence: GA 42860) | |
| 208600000X Surgery (Licence: MS 19035) | |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2021-09-23 |