| NPI | 1639581770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0122X Surgery, Plastic and Reconstructive Surgery (Licence: FL ME162792) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MT206879) |
| Enumeration Date | 2014-05-23 |
| Last Update Date | 2023-08-29 |