| NPI | 1649329319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101273227) |
| Additional Taxonomies | 208600000X Surgery (Licence: WA MD00046959) |
| 208D00000X General Practice (Licence: NE 23634) | |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2023-04-12 |