| NPI | 1326352592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WA MD60665317) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 4301096994) |
| 208600000X Surgery (Licence: MO 2015011067) | |
| Enumeration Date | 2010-07-30 |
| Last Update Date | 2026-06-15 |