| NPI | 1245591643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NM MD2019-1075) |
| Additional Taxonomies | 208600000X Surgery (Licence: MA 251879) |
| Enumeration Date | 2012-06-01 |
| Last Update Date | 2020-12-28 |