| NPI | 1629330386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WA MD60864136) |
| Additional Taxonomies | 208600000X Surgery (Licence: NC 2017-01459) |
| Enumeration Date | 2012-06-08 |
| Last Update Date | 2018-07-26 |