| NPI | 1316079411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0120X Surgery, Pediatric Surgery (Licence: FL ME101934) |
| Additional Taxonomies | 208600000X Surgery (Licence: MO 2009023875) |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2016-02-26 |