| NPI | 1538280011 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: GA 055112) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AR E5235) |
| 208600000X Surgery (Licence: OK 28998) | |
| 208600000X Surgery (Licence: AR E5235) | |
| Enumeration Date | 2007-04-03 |
| Last Update Date | 2022-10-13 |