| NPI | 1285615070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: AZ 31912) |
| Additional Taxonomies | 208600000X Surgery (Licence: NM MD2004-0779) |
| Enumeration Date | 2005-11-08 |
| Last Update Date | 2021-07-19 |