| NPI | 1316360621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0120X Surgery, Pediatric Surgery (Licence: WA MD61427686) |
| Additional Taxonomies | 208600000X Surgery (Licence: IA R-10539) |
| Enumeration Date | 2014-01-23 |
| Last Update Date | 2023-06-21 |