| NPI | 1356645063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MD C0004405) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0004405) |
| Enumeration Date | 2011-01-10 |
| Last Update Date | 2011-01-10 |