| NPI | 1396005773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: SC 86393) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MT201295) |
| 208600000X Surgery (Licence: NC 2021-01921) | |
| Enumeration Date | 2012-05-21 |
| Last Update Date | 2022-01-07 |