| NPI | 1497243497 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 208600000X Surgery (Licence: OH 35.154320)  | 
| Additional Taxonomies | 208600000X Surgery (Licence: NC 2023-00584)  | 
| 208600000X Surgery (Licence: AZ R76654)  | |
| Enumeration Date | 2018-04-25 | 
| Last Update Date | 2025-10-15 |