| NPI | 1558462697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207X00000X Orthopaedic Surgery (Licence: FL ME0074491) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: FL BH6217740-DEA #) |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2008-07-31 |