| NPI | 1376698936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: NY 136544) |
| Additional Taxonomies | 208600000X Surgery (Licence: MO 35630) |
| 208D00000X General Practice (Licence: NY 136544) | |
| 208D00000X General Practice (Licence: MO 35630) | |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2012-03-08 |