| NPI | 1417906991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WA AA8830778) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MD421172) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2019-01-24 |