| NPI | 1679830210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: WI 84768) |
| Additional Taxonomies | 208600000X Surgery (Licence: WA MD60783012) |
| Enumeration Date | 2012-04-20 |
| Last Update Date | 2025-01-15 |