| NPI | 1205801636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NY 140446) |
| Additional Taxonomies | 208600000X Surgery (Licence: MO 2004003230) |
| 208600000X Surgery (Licence: VT 042-0012289) | |
| 208600000X Surgery (Licence: CT 050199) | |
| 208600000X Surgery (Licence: WA 60186605) | |
| 208600000X Surgery (Licence: NH 15219) | |
| Enumeration Date | 2006-02-20 |
| Last Update Date | 2011-10-15 |