| NPI | 1518377670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2019-02912) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 5151009780) |
| Enumeration Date | 2014-04-29 |
| Last Update Date | 2025-08-13 |