| NPI | 1659460384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MS 13318) |
| Additional Taxonomies | 174400000X Specialist (Licence: MS 13318) |
| 174400000X Specialist (Licence: AL 28812) | |
| 208600000X Surgery (Licence: LA 17008) | |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2016-09-09 |