| NPI | 1588831861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: UT 7813558-1205) |
| Additional Taxonomies | 208600000X Surgery (Licence: TX M9454) |
| 208D00000X General Practice (Licence: TX M9454) | |
| Enumeration Date | 2008-05-14 |
| Last Update Date | 2022-07-21 |