| NPI | 1376049817 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 208600000X Surgery (Licence: FL ME175449) | 
| Additional Taxonomies | 208600000X Surgery (Licence: CO DR.0073780) | 
| Enumeration Date | 2018-04-03 | 
| Last Update Date | 2025-08-05 |