| NPI | 1578953485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CA A134319) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MD453845) |
| Enumeration Date | 2015-01-29 |
| Last Update Date | 2020-01-13 |