| NPI | 1376696179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: GA 66421) |
| Additional Taxonomies | 208600000X Surgery (Licence: NH RT1893) |
| 208600000X Surgery (Licence: PA MT188919) | |
| Enumeration Date | 2007-01-18 |
| Last Update Date | 2020-07-21 |