| NPI | 1578857371 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2086S0122X Surgery, Plastic and Reconstructive Surgery (Licence: UT 14203851) | 
| Additional Taxonomies | 208600000X Surgery (Licence: TX R9559) | 
| Enumeration Date | 2011-06-09 | 
| Last Update Date | 2025-07-17 |