| NPI | 1265421143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MI 4301111475) |
| Additional Taxonomies | 208600000X Surgery (Licence: OH 35082152) |
| Enumeration Date | 2005-10-14 |
| Last Update Date | 2025-03-20 |