| NPI | 1396891677 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WA MD60923826) |
| Additional Taxonomies | 208600000X Surgery (Licence: UT 54208301205) |
| 208600000X Surgery (Licence: WI 52151) | |
| Enumeration Date | 2007-01-26 |
| Last Update Date | 2022-01-28 |