| NPI | 1659639888 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TN DO0000003448) |
| Additional Taxonomies | 208600000X Surgery (Licence: VA 0102206054) |
| Enumeration Date | 2012-04-25 |
| Last Update Date | 2025-03-12 |