| NPI | 1497894315 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 208600000X Surgery (Licence: NV 12245) | 
| Additional Taxonomies | 208600000X Surgery (Licence: NY 242418) | 
| 208600000X Surgery (Licence: AZ 71758) | |
| Enumeration Date | 2007-02-06 | 
| Last Update Date | 2015-07-22 |