| NPI | 1609860600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: UT 5215595-1204) |
| Additional Taxonomies | 208600000X Surgery (Licence: ID O-220) |
| Enumeration Date | 2005-09-06 |
| Last Update Date | 2024-07-29 |