| NPI | 1629113147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NC 96-01117) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 118323) |
| 208600000X Surgery (Licence: NJ 34879) | |
| 208600000X Surgery (Licence: MI 4301081191) | |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2007-07-08 |