| NPI | 1578943833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 2021-02974) |
| Additional Taxonomies | 208600000X Surgery (Licence: SC 37648) |
| Enumeration Date | 2015-06-02 |
| Last Update Date | 2025-07-02 |