| NPI | 1366947756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MD D0104641) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MD484666) |
| Enumeration Date | 2018-03-27 |
| Last Update Date | 2025-08-21 |