| NPI | 1609495829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: PA MT221081) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA STUDENT) |
| Enumeration Date | 2020-04-09 |
| Last Update Date | 2020-06-03 |