| NPI | 1265724553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CA A122410) |
| Additional Taxonomies | 208600000X Surgery (Licence: VA 0101258761) |
| Enumeration Date | 2011-05-05 |
| Last Update Date | 2025-09-19 |